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Healthcare Clients: Are You Ready for HIPAA 5010 and ICD-10?

by Mark Davison November 28. 2011 14:37

HIPAA 5010 and ICD-10 Compliance Requirements

Beginning on January 1, 2012, a federal mandate will require health care providers, health plans and clearinghouses to use new standards in electronically processing electronic transactions claims, remittances, eligibility, and claims status requests/responses.  The changes are intended to improve transaction uniformity and streamline the reimbursement process.  Impacted organizations will need to upgrade processes and systems from current HIPAA 4010A1 transaction standards to the new 5010 standards, and complete internal and external testing, verification and validation to assure readiness and prevent disruption.  All impacted organizations must be ICD-10 compliant by October 1, 2013.


Why The Change?

  1. The government and industry’s shared goal of providing higher quality, lower cost health care
  2. The need to implement electronic data exchange for the vastly expanded ICD-10-CM and PCS code set transition that is mandated for compliance by October 1, 2013. 


What It Means To You

Are you impacted?  Yes, if your organization is a hospital, physicians office, clearinghouse, health plan, pharmacy, dentist or other participant in health care claim and reimbursement systems.

What should you do?   To successfully meet the deadlines health care organizations need to implement new computer software, or upgrade existing software, to process transactions using the upgraded ICD-10 code sets.  Computer software must be upgraded or enhanced, tested, and the results need to be documented to ensure compatibility prior to the deadline.  


Schedule and Deadlines

  • January, 2009 - Begin Level 1 activities (gap analysis, design, and development)
  • January, 2010 - Begin internal testing for HIPAA 5010 and NCPDP D.0
  • December, 2010 - Achieve Level 1 compliance (covered entities have completed internal testing and can send and receive compliant transactions)  
  • January, 2011 - Begin Level 2 testing period activities (external testing with trading partners and move into production; dual 4010A/5010 processing mode); begin initial ICD-10 compliance activities (gap analysis, design, development, and internal testing) 
  • January 1, 2012 – 5010/D.0 compliance date for all covered entities 
  • October 1, 2013 - The compliance date for ICD-10-CM and ICD-10-PCS 


Current Status

Many impacted organizations are struggling to get started with their remediation and testing projects, and have already missed important deadlines.  The availability of assessment and remediation tools, and the complexity and enormity of the effort for third parties and larger organizations, have combined to create a situation where more payers, providers and software vendors than expected are now behind in their plans to complete internal and external testing in time.  

Reflecting concern about the potentially disastrous effects of HIPAA claim rejections once the changes are enforced, the Centers for Medicare and Medicaid Services (CMS), a federal agency with the US Department of Health and Human Services, has instituted a 90-day grace period for HIPAA 5010 – meaning that although the compliance date remains January 1, 2012, the agency will not “initiate enforcement action” before March 31, 2012.


Apex3 HIPAA 5010 and ICD-10 Services 

Apex3 has a comprehensive offering of services to assist our clients with achieving compliance requirements ICD-10.  These services include the following:

  • Assessment – assesses the pending impact and remediation needed for internal departments and systems, and external parties, and generates a report that identifies all the required changes in transactions, software applications and processes
  • Program Management – defines goals and objectives, leadership, roles and responsibilities, tasks required to achieve compliance, issues management, creation of documentation, transition management, and measurement of progress via online dashboard
  • Remediation – methodology to track, test and document process and systems compliance changes needed, including creation of test databases and testing new third party software releases and internally developed upgrades and modifications, validation of interfaces with external trading partners, and process re-engineering to support changes in systems and technologies
  • Training – online e-learning tool developed by Certified ICD-10 professionals provides education without external training program costs
  • Revenue Recovery – monitors revenue streams and safeguard against noncompliant impacts.

The assessment and remediation phases are supported by an automated toolkit that supports the following:

  • automation of the assessment process across organizations, departments and systems
  • standardized remediation workplan tracks progress of task forces, committees, departments and vendors
  • best practice testing methodologies for managing test cases, test cycles, test scripts and results documentation
  • integrated governance/issues/risk management functionality
  • executive dashboard to monitor progress of stakeholders and participants.  

The tool links to documentation that can include vendor contracts, inventory of interfaces, and verification/validation of successful testing, consequently creating the documentation library necessary to support compliance efforts.  Reports can be used to track progress of outstanding compliance tasks that need to be completed prior to the deadline.

Contact Us Today at info@apex3llc.com for more information.



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About Mark Davison

Mark Davison

After 25+ years of working on and leading projects primarily in IT, I'm establishing this blog to share knowledge, ideas, tips and techniques regarding how to turnaround and fix troubled and failed projects

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